1245777564 NPI number — GEORGIA HEISSER

Table of content: (NPI 1245777564)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245777564 NPI number — GEORGIA HEISSER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GEORGIA HEISSER
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1245777564
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/24/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 21285
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BEAUMONT
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77720-1285
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7750 PARK NORTH DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BEAUMONT
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77708-2425
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
832-849-8298
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/24/2017

Additional Information

Authorized Official

Authorized Official Last Name:
HEISSER
Authorized Official First Name:
GEORGIA
Authorized Official Middle Name:
Authorized Official Title or Position:
MASSAGE THERAPIST
Authorized Official Telephone Number:
832-849-8298

Provider Taxonomy Codes

  • Taxonomy code: 305S00000X , with the licence number:  MT126192 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 225700000X . This is a "RESPIRATORY, DEVELOPMENTAL, REHAB & RESTORATIVE SERVICE PROVIDERS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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